Unlocking a Mystery
Mr. A was the kind of patient no doctor wanted to deal with.
A few years ago, he showed up in the office of Dr. Brian A. Fallon, complaining of nonstop headaches, which he was sure meant a brain tumor.
Tests showed nothing in the 52-year-old stockbroker’s head other than a normal-looking brain. And it was clear to Fallon--at the time a young psychiatric resident at Columbia University--that Mr. A had hypochondria.
Mr. A, however, was not convinced, says Fallon, who recalled their first meeting.
“I feel I have a serious medical illness, but the doctors won’t tell me what it is,” Mr. A ranted. “You are a psychiatrist. I don’t want to talk about my problems. I don’t care how well-trained you are, you can’t help me. I have a physical problem, not a mental one!”
What Fallon did next, however, not only convinced Mr. A that he did have hypochondria, it also convinced both doctor and patient that hypochondria is indeed “a serious medical illness.”
On a hunch, Fallon prescribed Prozac--which is used for depression and obsessive-compulsive disorder--because he believed Mr. A’s excessive fears mimicked the obsessive doubts and expectations of harm that people with OCD typically experience.
Within six weeks Mr. A was a new man. No headaches. No irrational fears. No obsession over dying.
Equally ecstatic was Fallon. To him, Prozac represented a key that unlocked a big, black box in psychiatry.
Until recently, hypochondriasis--unremitting fears about disease and a preoccupation with bodily symptoms despite reassurance from doctors--was considered one of the mental disorders most unyielding to psychotherapy. Medications were not considered useful.
Now, however, the picture is brightening for hypochondriacs and the exhausted retinue of doctors who try in vain to treat them for everything but hypochondria.
“It’s almost like a disorder coming out of the closet,” says Fallon, an assistant professor of clinical psychiatry at Columbia University.
Adding greatly to the new understanding of hypochondria is a New Jersey journalist named Carla Cantor, whose new book on hypochondria details her ordeal with the disorder. “Phantom Illness: Shattering the Myth of Hypochondria” (Houghton Mifflin) contains a forward by Fallon.
The progress in understanding hypochondria reflects the mind-body movement in medicine, in which emotions and thoughts are accepted as having a large effect on physical health.
Moreover, the promising use of Prozac for hypochondria suggests that the brain’s serotonin neurotransmitters may be highly influential in “mediating” this disorder, Fallon says. “Patients experience their bodily symptoms more intensely and experience a catastrophic reaction to those symptoms.”
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“Catastrophic” is a word Cantor can relate to. The first emotional bomb to fall in her life occurred when she was 17. Driving to a ski outing with a friend, Cantor’s car collided with a tractor-trailer. Cantor, now 41, walked away. Her friend was killed.
Morose and shaken, she developed an eating disorder in college and became preoccupied with the fear that she, too, would soon become ill or die. Cantor underwent years of psychotherapy, but the therapy never fully explored the idea that her emotional state might be a factor.
“We need to know what the psychological underpinnings are for each patient,” says UCLA psychologist Marc Schoen, an expert in mind-body medicine.
While some people may have a predisposition toward worrying, hypochondria seems to emerge to fill a need in someone’s life, he says.
For example, hypochondria can be used to seek attention or to punish oneself, to withdraw from personal responsibilities or because some traumatic event has led to a feeling of being unsafe. (In his preliminary research, Fallon has found a high rate of early psychological trauma, such as sexual abuse, among hypochondriacs.)
“People who become obsessed about having AIDS”--a common fear among hypochondriacs--”don’t feel real safe inside,” Schoen says. “They are scared about the world. A traumatic event shakes their foundation, and it goes down to the bottom brick, which is our health. When people aren’t safe, they focus on physical health.”
Cantor believes her car accident “fell on fertile ground.” But it was after the birth of her second child in 1990 that she developed a range of symptoms that convinced her she had lupus, another common fear among hypochondriacs. Repeated trips to doctors and a battery of tests showed nothing.
“I’m sure a lot of doctors, behind my back, rolled their eyes and couldn’t stand me,” Cantor says. “Hypochondriacs are begging the doctor to diagnose them and yet they are so frightened of having a disease that there is no pleasing them.”
Then, a few years ago, Cantor spotted a newspaper article on hypochondria and “something clicked,” she says. She made a series of phone calls that led to Fallon, who was recruiting patients for his study using Prozac. Cantor opted not to enter the study but found a nearby psychiatrist willing to prescribe Prozac. She felt better in weeks. Her pains disappeared. The hair she had been losing began to grow back. And her obsessive fear of having lupus no longer dominated her thoughts.
“The Prozac tones down the symptoms,” Cantor says. “By breaking the cycle of obsession and fear, I think you supplant a more relaxed state. People who suffer with this tend to be very hard on themselves. They are not able to enjoy life.”
With her recovery underway, the journalist in Cantor reemerged. She began researching the illness and was stunned to find out how common it is. Studies suggest that 6% to 10% of all people who visit doctors have no physical malady but have some degree of hypochondria. But Cantor believes that the stigma--the ugly connotation associated with the word “hypochondria”--keeps many people who suspect they are afflicted from seeking help.
“From very early on, I couldn’t understand the stigma,” she says of her decision to become the poster girl for the disorder. “When I realized how common hypochondria is, the whole stigma thing to me became absurd. To me, it didn’t seem so shameful that one could become so preoccupied with oneself and worried about one’s mortality. I think everyone can relate to this, whether or not you’ve had what psychiatrists call full-blown hypochondria.”
Cantor knew she had stumbled over the mother of all shameful conditions when she found there was no support group or organization for hypochondriacs.
And there is yet another reason to address the high incidence of hypochondria: It not only causes enormous amounts of human suffering, but it also costs society at the bank. Hypochondriacs visit doctors 10 to 14 times more often than the national average and cost the U.S. health care system $20 billion to $30 billion a year, according to an economic analysis.
“A lot of these visits are psychologically driven,” Schoen says. “If you don’t attend to this problem, these people will lead to escalating costs for most tests and more [medical] attention.”
David, a professional in his late 20s who lives in Los Angeles, can’t put a dollar amount on all the tests and exams he has endured while pursuing such diagnoses as Meniere’s disease, chronic fatigue syndrome, mononucleosis, diabetes, anemia and hypoglycemia.
“From the time I was 16 years old, I’ve gone to 30 or 40 different doctors, including the Mayo Clinic,” says David, who asked not to be further identified. “I was so sure I had diabetes or anemia or hypoglycemia. I’d look up this stuff and that just made the symptoms worse.”
David’s symptoms--headaches, backaches, dizziness--disabled him. “For 12 years I’ve done nothing because I’m so afraid. It was extremely hard to accept [a diagnosis of hypochondria] because the symptoms seemed so real. But even when I was a kid, my mom would say I was a hypochondriac because I’d run around the house spraying Lysol, and I would wash my hands any time I opened a door.”
On Prozac and in therapy, David says he still feels physical pain but is optimistic that he’ll conquer the disorder.
“I feel like I’m on a slow road to recovery. But I don’t think this can be fixed in a month.”
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What concerns Fallon and other pioneers in the treatment of hypochondria is that most hypochondriacs aren’t steered toward effective treatment.
“Doctors don’t like to call their patients hypochondriacs,” he says. “It still is a pejorative term. And, it is hard to be sure hypochondriacs are hypochondriacs. Sometimes people do have a physical illness. Doctors tend to be less likely to refer those patients to psychiatrists and are more likely to see them intermittently and do tests.”
Even in his attempts to recruit people for his next study on the effectiveness of Prozac, Fallon says doctors often fail to refer people to him. He’s had better luck finding research subjects through occasional television or magazine interviews.
“People who have this read these articles say, ‘That is what I have.’ They are quite happy that there is a name for it and there is something they can do about it,” says Fallon, who prefers to call the disorder Heightened Illness Concern to avoid the negative connotation.
“We are trying to change the way people view this . . . we are much more optimistic now,” says Dr. Javier Escobar, chairman of psychiatry at the Robert Wood Johnson Medical School in Piscataway, N.J. “Hypochondria is something psychiatrists have avoided for a long time. Patients don’t want to be viewed like this. They don’t like to show up in psychiatrists’ offices.”
Escobar, like Fallon, is enthusiastic about the family of antidepressants, called selective serotonin reuptake inhibitors, for treating hypochondria. Escobar has begun a study with an SSRI called Effexor on people who believe they have multiple chemical sensitivity or Gulf War syndrome, both disorders that produce a range of vague physical complaints but are difficult to diagnose.
Fallon has also discovered that most hypochondriacs are receptive to treatment once they accept the diagnosis.
“A lot of doctors have assumed that you can never work with these patients because they want to hold on to their symptoms,” he says. “My experience is that this is not true. I would say 90% of the patients I treat are quite eager to get better.
“There is a group of patients who have significant personality problems and are using symptoms as a way of seeking attention to themselves. But,” he says, “most people, if you can get rid of their need to be constantly reassured, they would be quite happy.”
